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CERB Intake Form

CERB Support Intake Form

Completion of this form will help facilitate your request.

Question Title

* 1. Project Name: (please provide both the full study title (descriptive) and the working study title

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* 2. PI contact information:

Name:

Email:

Institution Affiliation:

Department:

Phone:

Project Contact Name:

Project Contact Phone:

Project Contact Email:

Question Title

* 3. What is the category of your proposal/project?

Special projects

Full RFA

Other (please specify)

Question Title

* 4. What is the status of your proposal/project?

Pre-submission/writing

Pre IRB approval

Submitted unfunded

Funded/pre-implementation

Implemented

Question Title

* 5. What level of support are you seeking, from the CERB? (Check all that apply)

Community Ethics review and critique of proposal

Letter of Endorsement

Suggestions for enhancing the community engagement component

Serving as the project's Community Advisory Board

Other (please specify)

Question Title

* 6. Project Abstract:

Question Title

* 7. Project Abstract:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* 8. Full Research Proposal

Question Title

* 9. Full Research Proposal:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 10. The requested support is needed by:

Date

Question Title

* 11. Referred By:

Academic Partner

Community Member

CERB Member